Single Incision Transumbilical Laparoscopic Roux-en-Y Gastric Bypass: A First Case Report

TÉCNICA DE EXPOSIÇÃO DA JUNÇÃO ESOFAGOGÁSTRICA OBTIDA POR MEIO DE AFASTADOR FLEXÍVEL DE FÍGADO EM CIRURGIA BARIÁTRICA: ENSAIO CLÍNICO RANDOMIZADO

In the Roux-en-Y gastric bypass technique, classic laparoscopic surgical retractors are usually rigid, require an additional incision for its installation, or must be handled by an assistant during the surgical procedure, involving a risk of liver injury.

Consecutive Versus Selective Primary and Revisional Single Incision Laparoscopic Bariatric Surgery: Personal Experience in 330 Cases

BACKGROUND

This paper aims to retrospectively evaluate the feasibility, safety, and standardization for both consecutive primary and revisional SILS bariatric surgeries, and to analyze incisional hernia's prevalence, technical improvements, and limiting factors.

METHODS

A retrospective database review was undertaken involving, in Part I (Belgium), 290 consecutive SILS, including 80.68% primary bariatric surgeries, and 19.32% revisional gastric bypass, followed in Part II (Lebanon), by 40 selective primary SILS. Training for and standardization of the trans-umbilical technique was done for the operating room team, and was executed in part II.

RESULTS

The procedure of single incision was successfully completed in all of the 330 cases part I & part II. There was a need for additional salvage for one or two trocars in respectively 3.1% and 2.75% of the cases. There were no deaths or conversions in either group. Early complications included one medically healed fistula after revisional GB, and two secondary gastric and intestinal perforation requiring reoperations. Late surgical complications were: "3 patients (1.03%) in Part I and 2 (5%) in Part II suffered occlusions, requiring laparoscopic mesenteric defect's closure on an internal herniation." Twelve patients (4.1%) from part I and 5 (12.5%) in part II suffered an incisional hernia.

CONCLUSION

Selective SILS, when standardized, tends to be superior to consecutive SILS in terms of overall morbidity, operative time, and need for additional salvage trocars. Cost effectiveness and higher midterm rate of umbilical port site incisional hernia should be weighed against the beneficial cosmetic effect for the patient.

Evolution and Standardisation of Techniques in Single-Incision Laparoscopic Bariatric Surgery

Bariatric surgery has proven benefits for morbid obesity and its associated comorbidities. Laparoscopic approach is well established for bariatric surgery. Single-incision laparoscopic surgery (SILS) offers even more minimally invasive approach for the same with the added advantage of better cosmesis. We have developed and standardised the SILS approach at our institute. We share our experience and technical "tips" and modifications which we have learnt over the years. Technical details of performing sleeve gastrectomy and Roux-en-Y gastric bypass with special attention to liver retraction, techniques of dissection in difficult areas, creation of anastomoses and suturing have all been described. In our experience and in experience of others, single-incision bariatric surgery is feasible. Use of conventional laparoscopic instruments makes single-incision approach practical for day-to-day practice. Supervised training is essential to learn these techniques.

Solo Single-Incision Laparoscopic Resectional Roux-en-Y Gastric Bypass for Morbid Obesity with Metabolic Syndrome

With the advancement of laparoscopic devices and surgical technology, the era of minimal invasive surgery has progressed to reduced-port surgery, and finally to single-incision laparoscopic surgery (SILS). Several reports show successful application of SILS to various types of bariatric surgery. Oftentimes, this requires a skilled and experienced scopist to perform the procedure. To overcome the technical difficulties of single-incision Roux-en-Y gastric bypass, a manual scope holder was used instead of an assistant scopist, greatly stabilizing the field of view. This allows the surgery to be performed at any time without being influenced by the need of a highly experienced scopist. In this report, we describe in detail the world's first solo single-incision laparoscopic resectional Roux-en-Y gastric bypass.

Single-Incision Laparoscopic Sleeve Gastrectomy: Review and a Critical Appraisal

BACKGROUND

Single-incision laparoscopic surgery has attracted a great deal of interest in the surgical community in recent years, including bariatric surgery. Single-incision laparoscopic sleeve gastrectomy (SILSG) has been proposed as an alternative to the multiport laparoscopic procedure; however, it has yet to meet wide acceptance and application.

OBJECTIVE

We aim to summarize existing data on SILSG and check the procedure's feasibility, technical details, safety, and, if possible, outcomes.

MATERIALS AND METHODS

We checked the most important databases for studies concerning SILSG and included all these that summarized the criteria placed and contained the data needed for this review. We excluded case reports.

RESULTS

Nineteen studies complied with the criteria of our review, containing a total of 1679 patients. Their mean age has been 38.91 years and the mean preoperative body mass index has been 41.8 kg/m². In majority of cases (60.5%), a left upper quadrant incision has been preferred and in 97.6%, a commercially available multiport system has been picked. A wide variety of instruments have been used and mean operating time has been 94.6 minutes. One conversion to open surgery has been reported and 7.4% required the placement of additional ports. There was a complication rate of 7.38% (most common being bleeding with a rate of 2.5%) and a reoperation rate of 2.8%. Mean excess weight loss for a follow-up of 1 year was achieved in 53.7% of patients and was 70.06%. A tendency for less analgesia and better wound satisfaction has been reported.

CONCLUSIONS

SILSG is safe and feasible. However, there is insufficient evidence to recommend it as the new gold standard for sleeve gastrectomy in the place of conventional laparoscopic sleeve gastrectomy. Randomized controlled trials are needed to analyze the results and the possible benefits of this technique.

Postoperative pain after conventional laparoscopic versus single-port sleeve gastrectomy: a prospective, randomized, controlled pilot study

BACKGROUND

Laparoscopic approach is the gold standard for surgical treatment of morbid obesity. The single-port (SP) approach has been demonstrated to be a safe and effective technique for the treatment of morbid obesity in several case control studies.

OBJECTIVES

Compare conventional multiport laparoscopy (LAP) with an SP approach for the treatment of morbid obesity using sleeve gastrectomy in terms of postoperative pain using a visual analog scale (VAS) 0-100, surgical outcome, weight loss, and aesthetical satisfaction at 6 months after surgery.

SETTING

University Hospital, Spain.

METHODS

Randomized, controlled pilot study. The trial enrolled patients suitable for bariatric surgery, with a body mass index lower than 50 kg/m² and xiphoumbilical distance lower than 25 cm. Patients were randomly assigned to receive LAP or SP sleeve gastrectomy.

RESULTS

A total of 30 patients were enrolled; 15 were assigned to LAP group and 15 to SP group. No patients were lost during follow-up. Baseline characteristics were similar in both groups. A significantly higher level of pain during movement was noted for the patients in the LAP group on the first (mean VAS 49.3±12.2 versus 34.1±8.9, P = .046) and second days (mean VAS 35.9±10.2 versus 22.1±7.9, P = .044) but not the third day (mean VAS 20.1±5.2 versus 34.12.9 ±4.3, P = .620). No differences regarding pain at rest, operative time, complications, or weight loss at 6 months were observed. Higher aesthetical satisfaction was noticed in SP group.

CONCLUSIONS

In selected patients, SP surgery presented less postoperative pain in sleeve gastrectomy compared with the conventional laparoscopic approach with similar surgical results.

Transumbilical videolaparoscopic (single site) liver biopsy with laparoscopy equipment

INTRODUCTION

Liver diseases have a high incidence in the whole world. In order to diagnose, stage and follow these diseases it is often necessary the execution of liver biopsy. There are many possible ways to perform the procedure and the rise of transumbilical endoscopic surgery (TUES) brings to the medical practice an additional good option.

MATERIALS AND METHODS

The study is prospective, nonrandomised and cohort type. It involves 42 patients who underwent liver biopsy through TUES using conventional video laparoscopic material.

RESULTS

Among the patients 18 (42.86%) underwent isolated liver biopsy and 24 (57.14%) to liver biopsy associated with umbilical hernia repair. Within those, 27 (64.28%) were male and 15 (35.71%) female. The average body mass index (BMI) was of 27.26 kg/m(2), 10 were in the normal BMI range, 24 (57.14%) were in the overweight range, 6 (14.28%) had class I obesity and 2 (4.76%) had class II obesity. In none of the cases the procedure was converted to regular video laparoscopy, all the patients were discharged in the day after the procedure and reported a satisfactory aesthetic result.

CONCLUSIONS

The study shows that liver biopsy using TUES has applicability and good results, including in obese patients that would have a contraindication to other methods.

Single-incision sleeve gastrectomy versus laparoscopic sleeve gastrectomy. A 2-year comparative analysis of 600 patients

BACKGROUND

This is a 2-year study to evaluate the feasibility; outcomes in terms of postoperative pain, weight loss, and complication rates; and cosmesis of the single-incision sleeve gastrectomy versus the conventional multiport sleeve gastrectomy.

METHODS

A prospective comparative analysis was done in 300 patients in each arm who underwent laparoscopic sleeve gastrectomy and single-incision sleeve gastrectomy from September 2009 till January 2012. Both groups were matched for age and BMI. Postoperative pain scoring was done using visual analogue scale. Outcomes in terms of pain score, scar satisfaction score, excess weight loss, resolution of co-morbidities, and complications were compared in both groups at the end of 6 months, 1 year, and 2 years.

RESULTS

Female patients preferred to undergo single-incision sleeve gastrectomy. Operating time and intraoperative blood loss were comparable in both groups. Visual analogue scale (VAS) scoring revealed lesser postoperative pain in the single-incision group. Excess weight loss and resolution of co-morbidities were also comparable in both groups at 6 months, 1 year, and 2 years. Incisional hernia was seen in 3 patients (1%) in the single-incision group. Leak rate was comparable. Cosmetic satisfaction was superior in patients who underwent single-incision surgery.

CONCLUSIONS

Surgical outcomes are comparable in both groups at the end of 2 years. The myth of high long-term incisional hernia rate after single-incision surgery has been dispelled. Single-incision surgery is less painful with better cosmesis. It has come of age and should no longer be considered as an experimental procedure.

Transumbilical single-incision laparoscopic subtotal gastrectomy and total intracorporeal reconstruction of the digestive tract in the treatment of benign peptic ulcers

BACKGROUND

Single-incision laparoscopic surgery is being applied increasingly in many surgical specialties. However, few reports are available regarding its use in the treatment of benign peptic ulcer disease.

METHODS

We report here on nine patients with gastric or duodenal ulcers who underwent transumbilical single-incision laparoscopic subtotal gastrectomy (SILSG) between November 2010 and June 2013. All procedures were performed with conventional laparoscopic instruments placed through a single operating portal of entry created within the umbilicus. Total intracorporeal gastrojejunostomy or gastroduodenostomy was then performed for reconstruction of the digestive tract.

RESULTS

Only one case required conversion from single-incision to multiple-incision surgery. Among the eight patients who successfully underwent SILSG, total intracorporeal gastroduodenostomy was performed in two and gastrojejunostomy in six. The mean operation time was 290 ± 50 min (range 230-360 min), and blood loss was 200 ± 66 mL (range 100-300 mL). The patients recovered fully, and the single umbilical scars healed well.

CONCLUSIONS

We believe this is the first report of SILSG with total intracorporeal gastrojejunostomy or gastroduodenostomy in the treatment of benign peptic ulcers. On the basis of this initial experience, SILSG for this indication in the hands of experienced surgeons appears to be feasible and safe.

Single-incision laparoscopic sleeve gastrectomy versus multiport laparoscopic sleeve gastrectomy: analysis of 80 cases in a single center

BACKGROUND

Through efficacy and improved safety, multiport laparoscopic sleeve gastrectomy (LAPS-G) has emerged as an important and broadly available treatment option for people with severe and complex obesity. Because a single-incision laparoscopic sleeve gastrectomy (SILS-G) would be less invasive, we applied this novel surgical technique for a selected number of patients enrolled into our minimally invasive bariatric program.

SUBJECTS AND METHODS

A retrospective review of prospectively collected data from 80 morbidly obese patients who qualified for SILS-G or LAPS-G was performed from January 2011 to May 2012.

RESULTS

SILS-G and LAPS-G were performed in 40 patients, respectively. All patients were female. Mean age was 41 (range, 19-73) years (SILS-G, 37 [19-62] years; LAPS-G, 43 [24-73] years; P=not significant). Preoperative body mass index was 40.8 (35.1-45.0) kg/m(2) in the SILS-G group and 43.8 (35.0-47.8) kg/m(2) in the LAPS-G group (P=not significant). Total operative time was significantly lower in the SILS-G group (85±21 minutes) compared with the LAPS-G group (97±26 minutes) (P<.05). Median percentage excess weight loss was comparable in both groups (SILS-G, 57.2%; LAPS-G, 53.7%) at 6.6 months after surgery. Mean hospital stay was 5 days (SILS-G, 5 [4-24] days; LAPS-G, 6 [4-14] days; P=not significant). Complication rates were low in both groups: leakage, 2.5% in SILS-G and 0% in LAPS-G; bleeding, 2.5% in SILS-G and 2.5% in LAPS-G; and trocar-site hernia, 0% in both groups. Patients operated on with single-incision laparoscopy had a significantly better cosmetic outcome as assessed by a scar satisfaction assessment questionnaire (P<.01).

CONCLUSIONS

SILS-G is a feasible and safe operative procedure that leads to a significant reduction of total operative time compared with a multiport access procedure. Further potential benefits associated with single-incision laparoscopic surgery remain to be investigated objectively.

Transumbilical laparoscopic Roux-en-Y gastric bypass with hand-sewn gastrojejunal anastomosis

Single-port laparoscopic surgery has undergone significant development over the past 5 years. Single port is used in various procedures, including bariatric surgery. The aim of this paper is to describe a surgical technique for gastric bypass with a transumbilical approach (transumbilical gastric bypass-TUGB) with hand-sewn gastrojejunostomy, in selected patients who may be benefited by a better cosmetic result. The procedure begins with a transumbilical vertical incision. We use the GelPOINT single-port device and a 5-mm assistant trocar in the left flank (in the first two cases, a 2-mm subxiphoid liver retractor was used). A gastric pouch is made and calibrated with a 36-Fr bougie. The gastrojejunal anastomosis is performed by hand-sewing in two layers. A Roux-en-Y with a biliary limb of 50 cm and an alimentary limb of 120 cm is performed with a stapler. Three women were subjected to TUGB. The women were aged 28, 31, and 42 years; they had body mass indexes of 40.3, 33, and 38.2; and the operating times were 150, 200, and 150 min, respectively. The first two women underwent a Roux-en-Y gastric bypass (RYGB), and the last woman underwent a RYGB with a resection of the stomach remnant. There were no conversions to open or multitrocar techniques. No complications or deaths occurred. The three patients were satisfied with the cosmetic result. The technique described for TUGB is a feasible procedure for surgeons who have previous experience with the transumbilical approach.

Randomized prospective study to compare laparoscopic appendectomy versus umbilical single-incision appendectomy

INTRODUCTION

The use of single-incision laparoscopic surgery may represent an improvement over conventional laparoscopic surgery. In recent years, more and more articles have been published demonstrating the feasibility of this approach. Hence, for this reason, we present this randomized prospective study to compare the 2 techniques.

METHODS

Between September 2009 and December 2010, a total of 184 patients with a diagnosis of acute appendicitis and indicated for surgery were included in the study, of whom, 91 received an appendectomy via a single umbilical incision and 93 via conventional laparoscopy. The study protocol was approved by the ethical committee of the Virgen de la Arrixaca University Hospital (Murcia). The study was registered on ClinicalTrials.gov with inscription number NCT0151529. All the operations were performed by the same team of surgeons.

RESULTS

As far as the demographical results of the study population are concerned, there were no significant differences between the 2 groups for age, weight, sex, body mass index, and removed appendix type. Operating time was longer with the single-port approach: 38.13 ± 13.49 versus 32.12 ± 12.44 minutes (P = 0.02). Significant differences were observed for postoperative pain, which was measured on the visual analog scale, with less pain reported in the single-incision group: 2.76 ± 1.64 versus 3.78 ± 1.76 (P < 0.001). There were no significant differences between the 2 groups for early and late complications and lengths of hospital stay measured in postoperative hours.

CONCLUSIONS

The transumbilical single-port approach is seen as a feasible technique for performing appendectomy. It does not increase the rate of complications and represents a possible alternative to conventional laparoscopic appendectomy.

Single-incision Laparoscopic Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy has gained popularity and acceptance among bariatric surgeons, mainly as a result of its low morbidity and mortality. Single-incision laparoscopic surgery (SILS), the most recent development in minimally invasive surgery, allows operations to be carried out through only a single incision using special ports. To further minimize the trauma of access incisions, we applied the SIL sleeve gastrectomy on a selected number of patients enrolled into our minimally invasive bariatric program. Between June 2010 and May 2012, 40 consecutive female patients underwent SIL sleeve gastrectomy. All data (demographic, morphologic, operative, and follow-up data) were prospectively collected in a computerized data bank. All patients were female. Mean age was 37 years (range, 19 to 62 years), preoperative body mass index was 40.8 kg/m2 (range, 35.1 to 45.0 kg/m2), and excess weight loss was 57.2 per cent at 6.6 months after surgery. Total operative time was 85 ± 21 minutes and mean hospital stay was 5 days (range, 4 to 24 days). Of the patients, two (5%) sustained postoperative complications such as leakage from the suture line and hemorrhage one in each case. There was no trocar site hernia. SIL sleeve gastrectomy seems to be an effective surgical option for the treatment of morbid obesity. During the first 6 months after the operation, weight loss was excellent. These results are at present comparable to those of multiport sleeve gastrectomy. SIL sleeve gastrectomy is safe and feasible and can be performed without changing the existing principles of this procedure.

Transumbilical single-incision laparoscopic fundoplication: a new technique for liver retraction using cyanoacrylate

BACKGROUND/AIM

Single-incision laparoscopic fundoplication is not widespread because of its technical difficulty. An additional stay suture or retractor is often needed for liver retraction during the procedure. Here, we share our 7 cases to demonstrate the feasibility of transumbilical single-incision laparoscopic fundoplication with a new technique for liver retraction without any stay suture or retractor.

PATIENTS AND METHODS

From March 2010 to October 2011, 3 patients with achalasia underwent a transumbilical single-incision laparoscopic Heller-Dor operation, and 4 patients with hiatus hernia underwent transumbilical single-incision laparoscopic hernioplasty and Nissen fundoplication. The procedures were attempted transumbilically by using three rigid trocars (one was 10 mm, and two were 5 mm) inserted through the 2-cm umbilicus incision. Conventional laparoscopic instruments were used. Adequate retraction of the liver was achieved by binding the lateral left lobe of the liver to the diaphragm with cyanoacrylate.

RESULTS

The pneumoperitoneal time was 115-170 minutes, and blood loss was 15-50 mL. There were no intra- or postoperative complications. The hospital stay was under 6 days for all patients. The umbilical incision healed well with satisfactory cosmetic effect.

CONCLUSIONS

The transumbilical single-incision laparoscopic technique in the treatment of achalaisa and hiatus hernia is feasible for an experienced laparoscope surgeon with excellent cosmetic effect. Cyanoacrylate, when used as described, offers a safe and simple solution to the problem of liver retraction, thus obviating the need for a stay suture or liver retractor.

Single-access laparoscopic adjustable gastric band removal: technique and initial experience

BACKGROUND

Single-access laparoscopy (SAL) has gained significant interest in recent years. Potential benefits, beyond cosmetic outcomes, could be reduction of abdominal trauma, decreased risk of incisional hernia and diminished postoperative pain. Technique and initial experience in patients submitted to laparoscopic adjustable gastric band removal (LAGBR) through SAL is reported here.

METHODS

Between December 2009 and March 2012, 14 patients (9 females, 5 males) underwent LAGBR through SAL. Indications for operation were band intolerance (11), pouch dilatation (2) and insufficient weight loss (1). The mean age was 40.3 ± 9.1 years (range 26-57), and the mean interval time between LAGB placement and removal was 94.7 ± 41.9 months (range 37-157). The mean weight and the mean body mass index at the time of LAGBR were 89.3 ± 17.6 kg (range 65-119) and 30.6 ± 4.5 kg/m(2) (range 25.3-36.7), respectively. Technically, the previous port site scar was used as the single-access site to the abdominal cavity. An 11-mm reusable trocar was adopted for a 10-mm regular scope, besides curved reusable instruments.

RESULTS

No patients required conversion to open surgery and none necessitated additional trocars. The mean laparoscopic time was 24.6 ± 7.9 min (range 13-37), and the mean final scar length was 3.6 ± 0.3 cm (range 3-4). Two patients experienced early postoperative complications. The mean hospital stay was 1.3 ± 1.1 days (range 1-5). The mean follow-up time was of 18 ± 9.8 months (range 3-30), and there were no late complications.

CONCLUSIONS

LAGBR can be safely performed through SAL. Thanks to this technique, the laparoscopic working triangulation is established as well as the ergonomic positions of the surgeon. Due the use of only reusable material, the cost of this SAL remains similar to multiport laparoscopy.

Single-incision transumbilical (SITU) surgery after SITU laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Recently, single-incision transumbilical (SITU) laparoscopic bariatric surgery has been adopted as an alternative option for treating morbid obesity. Patients prefer SITU because it leaves minimal scarring. However, second surgery after SITU is a new challenge for surgeons. Here, we report on the safety and results for patients at a university hospital who underwent second surgery with the SITU procedure after SITU-laparoscopic Roux-en-Y gastric bypass (LRYGB).

PATIENTS AND METHODS

From November 2008 to May 2011, in total, 78 morbidly obese patients underwent SITU-LRYGB. After follow-up, 7 cases required reoperation with the SITU procedure because of dilated gastrojejunostomy in 1 patient, intractable hiccups in 1 patient, gallstones in 2 patients, and internal hernia from Petersen's defect in the remaining 3 patients. SITU was repeated via the previous umbilical incision to avoid creating a new scar. Three trocars were inserted separately, and pneumoperitoneum was created. The surgical procedures were performed with straight instruments. All surgical results and complications were recorded.

RESULTS

The procedure was successfully completed in all 7 patients without addition of trocars or conversion to conventional LRYGB or open procedure. Mean surgical time was 63±23 minutes. There were no intraoperative complications or postoperative wound complications noted in 3 months of follow-up.

CONCLUSIONS

Second surgery can be successfully done via a single umbilical incision after SITU-LRYGB, with reasonable operative time and good recovery, without additional abdominal scarring.

Transumbilical single-port sleeve gastrectomy: initial experience and comparative study

BACKGROUND

Sleeve gastrectomy is gaining relevance in the surgical armamentarium against obesity. The transumbilical single port has proved to be an attractive and safe alternative for a variety of minimally invasive abdominal surgeries. The purpose of this study is to evaluate the initial results of a group of patients operated by single-port sleeve gastrectomy compared with a group operated by conventional laparoscopic technique.

PATIENTS AND METHODS

We present a prospective cohort study of two groups of consecutive patients with body mass index (BMI) between 35 and 55 kg/m(2), with an indication of sleeve gastrectomy. In 20 patients, we used a transumbilical single-port (TUSP) technique; in 22 patients, we used the conventional laparoscopic (CL) technique. All surgeries were performed between June and December 2009 in the Gastrointestinal Surgery Department of Hospital Clínic, Barcelona. The same medical team, in a standardized fashion, carried out all surgeries.

RESULTS

There were no differences between groups in body mass index (BMI), age, sex, number and type of comorbidities, or history of previous abdominal surgery. Operative time (79.2 min) was significantly higher in the TUSP group (p = 0.002) than in the CL group (54.1 min). There were no conversions to open surgery in any of the patients operated upon via CL, but one conversion to laparoscopic surgery, requiring the addition of three trocars, in the TUSP group. There were no significant differences in morbidity or hospital stay between the groups. Percentage excess weight loss and excess BMI loss at 3 and 6 months, as indexes for improvement and resolution of comorbidities associated with obesity, showed that there were no significant differences between the groups.

CONCLUSIONS

Transumbilical single-port sleeve gastrectomy has proved to be safe, technically feasible, and reproducible, with results that are similar to those obtained with conventional laparoscopic surgery.

Single-port laparoscopic floppy Nissen fundoplication: a novel technique with the aid of the Cerrahpasa retractor

With the advent of single-port laparoscopy, the spectrum of abdominal surgeries performed is widening. The retraction of the left lobe of the liver in the upper gastrointestinal procedures is a critical maneuver with its added possible complications. In our study, we used the Cerrahpasa retractor (trademark pending by E. Eyuboglu and T. Ipek) for the retraction of the left liver in 22 patients with a different concept other than using the suturing or silk lace techniques described in previous studies. In our technique, the potential of tearing the liver or other anatomical structures is minimal. We believe that, with the aid of our Cerrahpasa retractor, the problem of liver retraction is being solved by a simple and safe technique.

Single incision laparoscopic ventral hernia repair

This study suggests that single incision laparoscopic ventral hernia repair is technically feasible, effective, and reproducible.

Background and Objectives:

Laparoscopic ventral hernia repair (LVH) requires several skin incisions for trocar placement. We have developed a single incision approach to LVH repair. The technique was introduced in clinical practice to any consenting patients who were candidates for a standard multi-port laparoscopic hernia repair. A consecutive series of patients was then followed to evaluate feasibility.

Methods:

Over an 8-month period, 14 patients (9 females, 5 males) underwent LVH repair by an academic surgeon. One of 2 access methods was used in each patient through a single 1.5-cm to 2-cm skin incision. One technique utilized two 5-mm ports with a temporarily placed 11-mm port for mesh insertion. The second technique utilized the SILS port (Covidien, Norwalk, CT). Standard or roticulating laparoscopic instruments were used with both techniques.

Results:

Range (mean) BMI: 23 to 59 (38), Age: 26 to 73 years (53), Duration: 37 to 87 minutes (57), Defect size: 1cm to 8cm (2), 3 with Swiss-cheese defect hernias. The procedure was successfully performed in all patients. No conversions to a multiple-port approach or to an open procedure were necessary. There were no mortalities, major complications, or recurrences during the mean follow-up period of 4 weeks.

Conclusion:

Single incision ventral hernia repair is technically feasible, effective, and reproducible. The technique is easy to master, and safe for any patient who is a candidate for laparoscopic ventral hernia repair. Further data collection with long-term follow-up will be needed to ensure equivalent outcomes. There will be demand for this approach by patients for cosmetic reasons, and it may serve as a bridge to natural orifice techniques.

Single-incision laparoscopic bariatric surgery

BACKGROUND

Bariatric surgery has been established as the best option of treatment for morbid obesity. In recent years single-incision laparoscopic surgery (SILS) has emerged as another modality of carrying out the bariatric procedures. While SILS represents an advance, its application in morbid obesity at present is limited. In this article, we review the technique and results of SILS in bariatric surgery.

METHODS

The PubMed database was searched and totally 11 series reporting SILS in bariatric surgery were identified and analyzed. The case reports were excluded. Since 2008, 114 morbidly obese patients receiving SILS bariatric surgeries were reported.

RESULTS

The procedures performed included SILS gastric banding, sleeve gastrectomy and gastric bypass. No mortality was reported in the literatures. Sixteen patients (14.05%) needed an additional incision for a liver retractor, a trocar or for conversion. Only one complication of wound infection was reported in these series. All the surgeons reported that the patients were highly satisfied with the scar.

CONCLUSION

Because of abundant visceral and subcutaneous fat and multiple comorbidities in morbid obesity, it is more challenging for surgeons to perform the procedures with SILS. It is clear that extensive development of new instruments and technical aspects of these procedures as well as randomized studies to compare them with traditional laparoscopy are essential before these procedures can be utilized in day-to-day clinical practice.

A novel surgical technique: single-incision transumbilical laparoscopic Roux-en-Y gastric bypass

Conventional laparoscopic Roux-en-Y gastric bypass (LRYGB) is a gold standard for bariatric surgery, but the procedure requires five to seven incisions for placement of multiple trocars and thus may produce less-than-ideal cosmetic results. We have developed a new approach, single-incision transumbilical LRYGB (SITU-LRYGB) to treat morbid obesity. We compared the surgical results and patient satisfaction in a study of five-port LRYGB and SITU-LRYGB. Fifty morbidly obese patients (14 males, 36 females) underwent either Roux-en-Y gastric bypass with five-port LRYGB or the SITU-LRYGB approach. During the operation, we used a novel intraoperative liver traction method with a “liver suspension tape” that we specifically designed for SITU-LRYGB. Compared to five-port surgery with SITU-LRYGB, there were no intraoperative complications, wound healing was excellent, and there was no abdominal scarring. SITU surgical time was longer than that with five-port LRYGB (99.8 vs. 67.6 min, P < 0.001). Patients treated with the five-port method were more obese than those in the SITU group (127.9 vs. 112.4 kg, P = 0.016). After the bariatric surgery, no difference in comorbidity was found in both groups. Patient satisfaction was greater with SITU than with the five-port method (4.48 vs. 3.96, P = 0.006). Roux-en-Y gastric bypass can be successfully achieved via a single umbilical incision, a method that provides a short operative time and good recovery and eliminates abdominal scarring.

Single-incision Laparoscopic Surgery (SILS) in general surgery: a review of current practice

Single-incision laparoscopic surgery (SILS) aims to eliminate multiple port incisions. Although general operative principles of SILS are similar to conventional laparoscopic surgery, operative techniques are not standardized. This review aims to evaluate the current use of SILS published in the literature by examining the types of operations performed, techniques employed, and relevant complications and morbidity. This review considered a total of 94 studies reporting 1889 patients evaluating 17 different general surgical operations. There were 8 different access techniques reported using conventional laparoscopic instruments and specifically designed SILS ports. There is extensive heterogeneity associated with operating methods and in particular ways of overcoming problems with retraction and instrumentation. Published complications, morbidity, and hospital length of stay are comparable to conventional laparoscopy. Although SILS provides excellent cosmetic results and morbidity seems similar to conventional laparoscopy, larger randomized controlled trials are needed to assess the safety and efficacy of this novel technique.

Single-access transumbilical laparoscopic nissen fundoplication performed with new curved reusable instruments

INTRODUCTION

The authors report a single-access laparoscopic Nissen fundoplication (SALN) performed with new curved reusable instruments.

CASE REPORT

A 21-year-old woman sought care for symptomatic grade B esophagitis and hiatal hernia. A reusable 11-mm trocar was inserted in the umbilicus and a 10-mm, 30° angled, nonflexible, standard length scope was used. Curved reusable instruments (Karl Storz-Endoskope) were transumbilically introduced without trocars. The left hepatic lobe was retracted thanks to the distal curve of the grasper. The cruraplasty and wrap were performed using curved needle holder and intracorporeal sutures.

RESULTS

No extraumbilical trocar was necessary. Laparoscopic time was 108 minutes, and umbilical scar length was 16 mm. Discharge was allowed after 48 hours.

CONCLUSIONS

SALN is feasible to be performed with curved reusable instruments, which avoid the conflict between the instruments' tips inside the abdomen or between the surgeon's hands outside. Cost of the procedure remains similar to standard laparoscopy because only reusable material is used.

Single-incision sleeve gastrectomy using a novel technique for liver retraction

Single incision laparoscopic access appears to be a safe, feasible technique for performing laparoscopic sleeve gastrectomy.

Introduction:

Laparoscopic sleeve gastrectomy has rapidly gained popularity in the field of bariatric surgery, mainly due to its low morbidity and mortality. Traditionally, 4 to 6 trocars are used. Single-access surgery has emerged as an attempt to decrease incisional morbidity and enhance cosmetic benefits. We present our initial 7 patients undergoing single-incision laparoscopic sleeve gastrectomy using a novel technique for liver retraction.

Methods:

Patients who underwent single-incision laparoscopic sleeve gastrectomy between March 2009 and May 2009 were analyzed. A 4-cm left paramedian incision was used. Laparoscopic sleeve gastrectomy was performed in a standard fashion using a 40 French bougie.

Results:

Seven patients underwent single-incision sleeve gastrectomy at the University of Illinois at Chicago. They were all female with a mean age of 34 years. Preoperative BMI was 49kg/m² (range, 39 to 64). There were no intraoperative complications. Mean operative time was 103 minutes. Estimated blood loss was minimal. All 7 patients were discharged on postoperative day 2 and were doing well without any complications at 3.1±0.7 months after surgery.

Conclusion:

Single-incision laparoscopic sleeve gastrectomy is safe and feasible and can be performed without changing the existing principles of the procedure. Our technique for internal liver retraction provides adequate exposure and is reproducible. Development of improved standard instrumentation is required for this technique to become popular.

Single-incision laparoscopic gastric bypass for morbid obesity

BACKGROUND

Single-incision laparoscopic surgery (SILS) has been developed with the aim of reducing the invasiveness of traditional laparoscopy.

METHODS

The technique of single-incision laparoscopic gastric bypass performed through a single intra-umbilical incision was adopted in 16 obese patients and minutely described. Fourteen patients underwent single-loop gastric bypass and two patients underwent "double loop" (Roux-en-Y) gastric bypass.

RESULTS

Operating time was less than 2 h in all cases. All procedures were completed with the single-access technique. There were no major per-operative complications. Patients were early-discharged after an upper GI examination and restoration of a liquid diet.

CONCLUSIONS

Emerging technology has contributed to the diffusion of SILS; single-incision laparoscopy is validated and established in cholecystectomy and is gaining acceptance in other techniques also. High technical skill is required for manipulating, measuring, and suturing the bowel with articulated instruments. However, randomized, controlled trials are required to determine the real advantages of this technique in comparison with standard laparoscopy.

Single-incision laparoscopic right colectomy: experience with 17 consecutive cases and comparison with multiport laparoscopic right colectomy

BACKGROUND

Recently, single-incision laparoscopic surgery has begun to develop as an extension of standard laparoscopic minimally invasive procedures. However, there have been a limited number of reports of single-incision procedures in colorectal disease.

PURPOSE

The aim of this study is to describe our initial experience with single-incision laparoscopic right colectomy and to make comparisons with the current standard of care, multiport laparoscopic right colectomy.

METHODS

Data from consecutive patients undergoing single-incision laparoscopic right colectomy were analyzed and compared with case-matched multiport laparoscopic right colectomies. Indications for surgery, type of port used, operative time, number of nodes harvested, length of hospital stay, and complications were the outcomes measured.

RESULTS

During the study period, 17 patients underwent single-incision laparoscopic colectomy. Of the planned single-incision laparoscopic cases, 15 (88%) were completed with a single incision, whereas 2 required an additional port placement. There were no conversions to open surgery during any of the cases. Indications for surgery were similar between the 2 groups. Operative time was not significantly different in single-incision laparoscopic right colectomy compared with multiport laparoscopic right colectomy (139 min vs 134 min, respectively; P = .61). Length of stay and number of nodes harvested also had no significant differences between the 2 groups. There was one death after discharge to home secondary to pulmonary embolism and one delayed thermal injury in the single-incision laparoscopic group.

CONCLUSION

Single-incision laparoscopic right colectomy is feasible, and appears to have results similar to standard multiport right colectomy in our initial comparisons. Ongoing development in instrumentation may help to further shorten operative time and minimize complications, and may make this an equivalent or preferred method for minimally invasive colorectal surgery. Large, prospective, randomized, controlled trials should be conducted to further compare the safety and efficacy of this approach.

On the road to single-site laparoscopic adjustable gastric banding: lessons learned from 60 cases

BACKGROUND

Single-site laparoscopic surgery is a promising emerging technique with potential to decrease postoperative pain, reduce port-site complications, and improve cosmetic results. Laparoscopic adjustable gastric banding (LapGB) is a procedure that lends itself well to single-site laparoscopic surgery because the surgery is confined to a single region of the body, the need for a larger incision for port implantation and the fact that bariartric patients are more likely to be body image conscious. The procedure is, however, technically challenging and potentially more time consuming and hazardous. To simplify learning, a hybrid technique that used multiple conventional trocars and laparoscopic equipment through a single periumbilical incision while retaining the use of the Nathanson retractor via a separate epigastric incision was developed. The authors' experience and results with this technique are described.

METHODS

This retrospective review describes the prospectively collected data for the first 60 consecutive cases completed using the minimally invasive technique described.

RESULTS

The 60 cases in this study comprised 12 men and 48 women with an average age of 39 years (range 20-59 years). Their average body mass index (BMI) was 39.1 kg/m(2) (range 32-52 kg/m(2)). Four patients (6.7%) needed an additional port either for hemostasis or for access difficulties. Concomitant hiatal hernia repair was performed for 13 patients. Five patients (8.3%) had superficial wound infection requiring oral antibiotic therapy and dressings. No other complications were observed. Overall, the average operating time was 55 min (range 30-160 min). For both surgeons, the learning curve was six cases, with a significant difference in the operating times between the first six cases and the remaining cases (p < 0.0001, Mann-Whitney U test).

CONCLUSIONS

The authors' early experience with the minimally invasive LapGB technique shows that it is feasible and safe. It can be used either as a bridging technique to single-site LapGB or on its own as a minimally invasive technique.

Laparoendoscopic single-site gastrectomy for a gastric GIST using double-bended instruments

BACKGROUND

Laproscopic single-site surgery is the natural evolution of minimally invasive surgery.

METHODS

A 70-year-old male was planned for a resection of a gastric GIST (gastrointestinal stromal tumor). A Triport trocar (Olympus, Aartselaar, Belgium) was placed through a 2-cm periumbilical incision. Besides the placement of a Nathanson liver retractor in the subxiphoidal position, no additional trocars had to be added. The partial gastrectomy was carried out by using clinical prototypes of double-bended intruments and of a "goose neck" videolaparoscope, all specially designed for single-port surgery.

RESULTS

Total operative time was 140 minutes, and estimated blood loss was 10 mL. No intra- or postoperative complications occurred. Hospital stay was 4 days. Final pathology revealed the complete resection of a GIST tumor of gastric origin.

CONCLUSIONS

We have demonstrated the technical feasibility and described the detailed surgical technique of laparoendoscopic single-site surgery gastric wedge resection.

[Single incision laparoscopic surgery]

One of the aims of the new technologies and techniques in minimally invasive surgery (MIS) is to achieve a surgery without or with minimal visible scars. Natural orifice transluminal endoscopic surgery (NOTES) might be considered to be a paradigm of this development but it has not yet been possible to implement this universally. Nevertheless, the resultant innovation of research into NOTES has enabled "bridge technologies" to be introduced that allow MIS to be developed with the required standards of efficiency and safety. The aim of this paper is to review the concept of single incision surgery and to classify the available tools for its development and implementation.

Preliminary surgical results of single-incision transumbilical laparoscopic bariatric surgery

Background

Recently, single-incision laparoscopic surgery (SILS) has been used for bariatric procedures, and this surgery is considered a type of minimally invasive surgery. When SILS is performed via the transumbilical route, the resultant abdominal wound is hidden and the cosmetic outcome is better. However, because of the small angle of manipulation and difficulty in liver traction, this technique is not used to perform complex bariatric surgery. In this prospective study, we used our novel technique, which involves the use of a liver-suspension tape and umbilicoplasty of an omega-shaped incision (omega umbilicoplasty), to perform laparoscopic bariatric surgery via the single-incision transumbilical (SITU) approach. We then assessed the safety and effectiveness of our surgical technique.

Methods

We started performing and developing this technique from December 2008. Until July 2009, 40 consecutive patients underwent 40 bariatric procedures: two adjustable gastric band placements, six sleeve gastrectomies, and 32 Roux-en-Y gastric bypass operations, including five cases where concomitant cholecystectomy was performed.

Results

The mean operation time was 93.4 min and the mean duration of postoperative hospitalization was 1.15 days. No perioperative or postoperative complications or deaths occurred. Most patients were very satisfied with the cosmetic outcomes.

Conclusion

Our technique can be safely and effectively used for SITU laparoscopic bariatric surgery. This technique will soon be used for advanced abdominal surgeries besides bariatric ones.

Single-port laparoscopic surgery

Laparoscopic surgery performed through a single-incision is gaining popularity. The demand from the public for even less invasive procedures will motivate surgeons, industry, and academic centers to explore the possibilities and refine the technology. Although the idea seems quite attractive, there are several technological obstacles that are yet to be conquered by improved technology or additional training. The question of safety has yet to be answered and will require well-designed randomized control trials. Opponents to the approach argue that the size of the single incision (see Table 1) is frequently larger than all the standard laparoscopy incisions combined. On the other hand, proponents remember a similar argument from traditional open surgeons during the initial development of laparoscopy. That argument was quickly discredited when the immediate benefits oflaparoscopy were compared with patients undergoing surgery with small laparotomy incisions. During the development of a new technique, the learning curve exposes patients to risk and society to expense. LESS pioneers appear to have reached a level of comfort with technology and techniques that paves the way for scientific scrutiny. Perhaps, the surgical community will capitalize on this situation with randomized, controlled studies and sound evidence to support or refute the benefits of LESS. If we do not seize this opportunity, patient demand and industry's dual edge message of financial success versus fear of losing referrals will lead to a scenario similar to the development of laparoscopic cholecystectomy in the 1990s. Regardless of its future, the surgical community will still benefit from a renewed excitement as surgeons aim to continually reduce the amount of pain and trauma our patients must endure. In addition, technological advances on instrumentation will benefit the field of laparoscopy and improve patient care.